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\� .. r .c.-.. :-- ..ili._�� t--.J�l'>ieNErQ- •.'..+�...NMbdrfCi.:e..ra- n:K.._ Air - ems. •-— ..��- JI a.,ter. _.a. ��y�.v.�, <br /> AqU I!Y <br /> Ao. ,E.c G\ SAN JOAQUIN COUNTY <br /> IZI ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> \4 Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> c1q nhz� fyohe <br /> Facility Address: � Service Request#: <br /> V7 ?e)O /I �3_/,.�/I d���afid - sf�C / <br /> Onsite Service Technician's Name: ICC Se vice Technician/Installer Exp. Date: Manufacturer Trainin : <br /> r <br /> •2o <br /> SERVICE SERVICE <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic El Incon TS-STS <br /> ED line test ro rammed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: 20 � psi <br /> E] ��L� <br /> fail safe Serial #: J'� minutes T� <br /> ❑ NA <br /> sensor P P,1 r1� Secondary containment testing for: <br /> El positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> qlaon#ffsensor ❑ Testing for the above components are next due by: <br /> ❑ positive shutdown Model: 23tqJ2 e�, 4P) <br /> ❑ fail safe Serial #: <br /> Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> C Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> ❑ This UST facility is APPROVED to operate X This UST facility is NOT APPROVED to operate <br /> 40 VP <br /> 1 • VwAe r&22d ra <br /> jl2t.)W-r,-,�,rne av) W219t IJ-7,".1 L <br /> Q ` 14014 <br /> s b / NIL <br /> of <br /> THIS FAC Y 1S SUBJECT TO REINSPECTION AT ANY 1 AT EHD'S CURRENT • UR Y RATE. (,(JZfja <br /> Inspec ` �eceiv Ti <br /> Zf <br /> EHD 23-04 ,e4rml UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 L��� /_tZ17 LI-CM) U a A,l 7( <br />